CMS SOM App. A, Tag A-0174

of the length of time identified in the order.

Interpretive Guidelines §482.13(e)(9)

Restraint or seclusion may only be employed while the unsafe situation continues. Once the unsafe

situation ends, the use of restraint or seclusion must be discontinued.

Staff members are expected to assess and monitor the patient’s condition on an ongoing basis to

determine whether restraint or seclusion can safely be discontinued. The regulation requires that these

interventions be ended as quickly as possible. However, the decision to discontinue the intervention

should be based on the determination that the patient’s behavior is no longer a threat to self, staff

members, or others. When the physician or LIP renews an order or writes a new order authorizing the

continued use of restraint or seclusion, there must be documentation in the medical record that describes

the patient’s clinical needs and supports the continued use of restraint or seclusion.

The hospital policies and procedures should address, at a minimum:

• Categories of staff that the hospital authorizes to discontinue restraint or seclusion in accordance

with State law; and

• The circumstances under which restraint or seclusion is to be discontinued.

Survey Procedures §482.13(e)(9)

• Does the hospital have policies and procedures for ending restraint or seclusion? Do the policies

include a requirement to end the restraint or seclusion as soon as is safely possible?

• Does the medical record contain evidence that the decision to continue or discontinue the use of

restraint or seclusion was based on an assessment and re-evaluation of the patient’s condition?

• Interview staff to determine whether they are aware that use of a restraint or seclusion must be

discontinued as soon as is safely possible.